Running Head: PATIENT AUTONOMY IN NURSING

Patient Autonomy in Nursing:

An Examination of an Ethically Difficult Situation
Abigail Floyd
James Madison University

PATIENT AUTONOMY IN NURSING

Patient Autonomy in Nursing:

An Examination of an Ethically Difficult Situation
Introduction
In todays society, the field of nursing is plagued by many ethically difficult situations
involving patient autonomy. The nurse can be faced with situations where the patient wishes to
handle his or her medical care one way despite negative consequences to his health and recovery.
It has been stated that nurses may have difficulty advocating for the patients wishes due to the
fact that other healthcare professionals often operate in an authoritarian manner (Lindburg,
Fagerstrom, Sivberg, & Willman, 2014). Other factors can also be at play such as hospital
protocol or the nurses individually held beliefs that contradict the patients wishes. Another
difficulty is that the specific meaning of patient autonomy is often disagreed upon among nurses
(Lindburg et al., 2014). Building moral distress as well as moral residue arises from handling
these situations. More needs to be done to help nurses address these issues of patient autonomy
so that the moral residue of the nurse does not reach an overwhelming abundance. Many studies
have shown that nurses with high levels of moral residue and distress look for ways to exit the
field of nursing due to burnout and anxiety (Epstein & Delgado, 2010). With the current nursing
shortage, our society cannot afford to consistently lose nurses.
Background
On my second day of twelve hour clinical on a medical-surgical unit, I was caring for a
patient who was three days post-operation of a colon resection surgery. The patient was having
severe abdominal distention and had not demonstrated evidence that his bowels were functioning
after the operation. Early in my shift the patient requested to ambulate, as surgeons and the nurse
on the shift before me encouraged him to walk so that he could stimulate his bowels to move.

PATIENT AUTONOMY IN NURSING

However, as the day progressed, the patient became increasingly nauseated and uncomfortable,
so the doctor ordered Phenergan and ambulation. Fifteen minutes after the Phenergan was
administered, the patient stated that he did not want to ambulate due to his nausea and
exhaustion. I again encouraged the patient to walk and he seemed very reluctant. I requested that
another student help me with encouraging him to ambulate. Finally, the patient agreed to walk.
My nursing peer and I walked the patient a few feet down the hall and quickly turned around at
his request. An alternative route I could have taken would be allowing the patient to remain
seated and checking back in a few hours to see if he was ready to walk.
This situation was a moral dilemma for me, because I knew that the best thing for the
patient was to get up and ambulate in order to stimulate movement in the bowel and avoid an
ileus development. However, I also wanted to adhere to the patients wishes and promote patientautonomy as much as possible. I was very aware that the last thing the patient wanted to do was
get up when he was severely nauseated and in distress. My level of encouragement of the patient
to get up and walk was very strong because I knew it would stimulate his bowels and in turn,
decrease his nausea. However, I still wrestle with whether or not I did the right thing in getting
him up to walk. Nurses are supposed to honor patient autonomy and respect their requests. The
initial request of the patient was to not walk. I felt as if I had to check walking the patient off my
list because it was requested by the physician who has greater authority than me.
Methods/Findings
In order to analyze the ethically difficult situation, I will utilize James Madison
Universitys eight key questions. The eight key questions are based on fairness, outcomes,
responsibility, character, liberty, empathy, authority, and rights (James Madison University, n.d.).

PATIENT AUTONOMY IN NURSING

When compiled together, the eight key questions can be utilized to determine a reasoned solution
regarding an ethically difficult situation.
The first key question involves fairness and addressing needs in an equal way. In my
situation, the people I needed to be fair to were my patient, myself, the doctor, and the nurse I
was working with. The fairest way to meet the needs of everyone would be to make sure
everyone is involved in the situation and has a say in the matter. I believe that this occurred
except for the fact that the patient may not have had as much say as the doctor. The action that
receives the best short and long term outcomes would probably be to have the patient ambulate.
Walking with the patient with supervision is most likely not going to cause any harm to the
patient short or long term. It will help stimulate his bowels and speed up his recovery in the
hospital. The drawbacks are that he will probably be in some pain and discomfort while walking
and may be fatigued afterwards. Ultimately, this drawback is more desirable than the patient
developing an ileus. The responsibilities I hold in this situation are to provide nursing care in
accordance with American Nursing Association Standards as well as the standards of the hospital
and the James Madison University nursing program. The character I want to possess as a nurse is
to be as caring and open as possible with my patients. Because I explained the benefits of
walking with my patient, I believe I was open with him. In addition, I turned the patient around
when he requested to go back quickly. My patient should be given the liberty to handle his care
how he wishes. Because we strongly encouraged him to get up and walk despite his lack of
desire to do so, it is possible that liberty was violated in this situation. Empathy allows me to
look at this situation from another point of view. If I were the patient, I would be glad that the
nurse persevered in getting me up to walk. Initially, I may not have been pleased, but in the long
run I would have been thankful. My authority figures in this situation were the nurse I was

PATIENT AUTONOMY IN NURSING

working with, the doctor, and my preceptor. Because the nurse and doctor suggested I ambulate
the patient, I believe that I followed authority appropriately. My patient possesses the right to
make decisions about his medical care. His decision was strongly swayed by our persuasion, but
I believe this is acceptable because it is the nurses job to provide the patient with information to
improve their health.
For my situation, Provision 1.4 of the ANA Code of Ethics is of great relevance
(American Nurses Association [ANA], 2015). The provision, Right to Self-Determination, states
that all patients have the ability to make their own informed decisions about their health care.
Nurses may provide information necessary to informed decision making. They must not coerce
the patient in proving information (ANA, 2015). In my situation, the patient eventually stood up
to walk and ambulate on his own. Our level of persuasion was strong. However, I dont believe it
was coercive in any way.
Conclusion
After examining the James Madison Universitys eight key questions and the ANA Code
of Ethics, I believe that how I handled the situation was appropriate. If the situation happened
again, I would make sure to thoroughly explain why ambulating was necessary for the patient,
instead of briefly going over it. This way, the patient may have had more internal motivation to
get up. Overall, I believe the most good arose from ambulating the patient rather than keeping
him sedentary. Patient autonomy was not violated because the patient eventually consented to
getting up and walking. Because JMUs eight key questions were certainly beneficial in
analyzing my ethical dilemma, it may be helpful for nurses to utilize a framework such as JMUs
eight key questions in ethically difficult situations of practice as well.

PATIENT AUTONOMY IN NURSING

6
References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.
Retrieved from http://www.nursingworld.org/ethics/code/protected_nwcoe303.html
Epstein, E., & Delgado, S. (2010). Understanding and addressing moral distress. OJIN: The
Online Journal of Issues in Nursing, 15(3). doi:10.3912/OJIN.Vol15No03Man01
James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in action.
Retrieved from http://www.jmu.edu/mc/8-key-questions.shtml
Lindberg C., Fagerstrm C., Sivberg B. & Willman A. (2014) Concept analysis: Patient
autonomy in a caring context. Journal of Advanced Nursing 70(10), 22082221.
doi: 10.1111/jan.12412